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APPLICATION FOR PERMIT L26 Aw, r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,�STOCKTON, CA FEB 2 E989 Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'� '� (Complete in Triplicate) ( Mli;./vEWICwS Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the.work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. , j F• a, -i•. 5-C f L+ Job Address t City Lot Size f PM �i Owner's Name G. Address Phone '' Contractor 10 CQ4,AJ Address z dwa License No. 'c ;,PPhon e.Z9-51 ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _...._._OTHER —DISTANCE TO NEAREST:-SEPTIC TANK -,..a. "'"rSEWER LINES}: DISPOSAL FLb. _ ' OP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other C1 Delta Depth of Grout Seal - Type of Grout ❑ irrigation ---Approx. Depth Eastern Surface Seal Installed by- Repair Repair Work Done It Type of Pumpl H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'} -- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 11 DESTRUCTION ❑ (No septic system permitted if public sewer is "' .i — available within 200 feet.) I Installation will serve: Residence- srCommercial `Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table dep SEPTIC TANK ElType/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ a. ; Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 1 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth I Size i Number _ s a.—. ._ : SUMPS` :. —0 `Distance'lo nearest"- 'Well` Foundation" ' "�Propeity Line— "� — "' DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. I i Home owner or licensed agent's signature certifies the following. "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's c6mpensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,i shall employ persons subject to workman's compensa- tion laws of California." r The apP Icant�mu t call for ali re d inspections. Complete drawing on verse side. Signed ��J t . f .-. - Title: Date: l FO DEP A TMENT USE ONLY ' Application Accepted by �� Date Area ,,Pit or Grout Inspection by ( Date Final Inspection by Date- Additional Comments: } ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FE£ AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.i/s 5) ' EH 7426 �